RN2800

Yes, its still DKA, and the AG you calculated in not accurate, its 20 and not 14. The Pt has overcompensated by blowing off CO2. The bicarb is normally lower. Sounds like a Pt on day 2 or day three whose kideneys have responded and recovering bicarb gain. I like what the other nurse said about nausea and vomiting. Its a different metabolic process which is as simple as alkalosis due to H+ loss. When combined with a primary metabolic acidosis i can see how such a gas would cause confusion. Thanks for posting.

Hello, I have read online recently on EMCRIT that fluids are certainly first, and that the urgent need for rehydration and electrolyte replacement depends on the severity of dehydration. A patient with DKA who delays treatment, has a secondary infection present, or high lactate levels and thus profound metabolic acidosis will certainly need fluid resuscitation first. Giving insulin prior to restoring ECF balance can be risky, as it will drive down potassium. Not so important if your Pts K levels are already elevated, but the drop in K levels can be profound and dangerous when you then reydrate with only NS plus giving insulin boluses at the same time. Not to mention for most DKA patients, if the ketones are high enough, they will have an anion gap acidosis. Better to give Plasmalyte or a balanced solution that does not contain too much chloride. In the MedSurg and ICU floors we don't have plasmalyte so I'm wondering what the next best choice would be to rehydrate the ECF. Some DKA protocols call for as much as 3 L rehydration within the first hour, then you can give a bolus of insulin so the Pt will stop producing lactate. And as always it seems that the condition the kidneys are in would be a factor, or if the Pt has been down for awhile and has very elevated CK levels. Can anyone out there comment on (the best) fluid resuscitation in a DKA Pt that is also in ARF?

good point. a little attitude adjustment can make a big impact.